Conversations with ... Matthew Wynia, MD

GEORGE LUNDBERG, MD: Hello, and welcome. I'm Dr. George Lundberg, Editor-at-Large for MedPage Today. And we are in Chicago today having a conversation with Dr. Matthew Wynia, who is the director of the Institute for Ethics at the American Medical Association, an organization with which he has worked for about 15 years.

Dr. Wynia, thank you so much for being with us.

MATTHEW WYNIA, MD: Oh, my pleasure.

LUNDBERG: You have your medical degree from the University of Oregon, and then you have an MPH from Harvard, and you're an internist, and you also practice medicine in Chicago at the University of Chicago, part time I presume.

WYNIA: Yes.

LUNDBERG: Okay. You deal with ethics all the time. What are some of the key ethical issues that practicing physicians deal with in their office, in their hospital, in the ICU, wherever you want to take that question?

WYNIA: Probably the issues where most people immediately think of ethical dilemmas would be things like end-of-life care or where there may be conflicts within a family about the right way to move forward with a patient's treatment. And then I think the next thing where people sometimes think of ethical issues arising would be modern technologies; things like genetics, prenatal genetic diagnosis.

I actually think that probably the most important set of ethical issues that physicians are grappling with every day they don't always categorize as ethical issues.

LUNDBERG: Right, I understand.

WYNIA: So probably the ethical dilemma of our day is how to ensure that we are providing high value healthcare that meets the needs of individual patients who come to see us and also is attuned to the needs of the larger community to make sure we aren't breaking the bank on healthcare delivery.

I don't think many physicians on a day-to-day basis think about themselves as having those roles, and yet we clearly do have those roles, as both the advocate for the individual person sitting in front of us and as a steward of the shared resources that are entrusted to us through health insurance. Through the community.

You know, I practice infectious diseases. Most of my patients are on Medicaid, and, in a very real sense, every time I write a prescription for one of them, I'm spending public money.

LUNDBERG: Right.

WYNIA: And so it is important for me to spend that money wisely while also maintaining my responsibility to treat that patient as an individual the best I can.

LUNDBERG: So how do we put a red flag on these every-day kinds of actions of physicians so they realize it's not just dealing with who will pay for what and so forth, but the ethical basis for a decision? How do we make that clear?

WYNIA: Well, one of the practical ways that people are moving in this arena is to bring the patient into this conversation.

LUNDBERG: Shared decision making.

WYNIA: The shared decision making, team-based care, seeing the patient as part of the team making decisions, and even so far as having some financial understanding of what the decisions mean, both to themselves and to the larger community from which they come.

LUNDBERG: Well, how about a physician knowing what it's going to cost a patient before they prescribe something?

WYNIA: Exactly.

LUNDBERG: Or do something? Isn't that an ethical responsibility, really?

WYNIA: I believe it is. The problem is ...

LUNDBERG: It's hard to find.

WYNIA: It is, it's very difficult to find. And it's not the kind of thing where a physician can say, "Oh, today I'm going to make sure I know all this." Because the information may not even be available to them.

I had a patient just the other day who went to see a physician for a second opinion at another site and didn't realize that this was going to cost $3,000. And the patient came back to me, you know, very upset because of the charge that was accruing to him now and that was not covered by his insurance plan.

You know, he had no realistic way of knowing what it was going to cost before he went there. Much of this was in lab testing and so on. You don't really have a way. I, as a doctor, even warning him in advance, could not really tell him exactly -- or even roughly -- what it was going to cost him.

LUNDBERG: It's tough. I've written about what I call the economic informed consent. And tried to call attention to that for a long time, and doctors push back a lot saying, "I don't know, and I can't figure it out."

WYNIA: Right.

LUNDBERG: And we often don't know until after the fact whether an insurance company will or will not cover something.

WYNIA: That's right.

LUNDBERG: Now, do you staff CEJA, the Council on Ethical and Judicial Affairs? Is that one of your jobs?

WYNIA: No. I actually don't. There's a separate staff for the policy making part of the AMA's ethics group. I staff the research arm.

LUNDBERG: Okay.

WYNIA: So we do surveys of doctors and how they might handle ...

LUNDBERG: So would CEJA be an appropriate body to look at what we're talking about now?

WYNIA: Yes.

LUNDBERG: The economic informed consent? Has it done that, or do you know?

WYNIA: There are opinions in CEJA that relate to billing and collections and informed consent around economic issues. There are also opinions that touch on the various aspects of sort of giving patients skin in the game. Having patients be more involved in making tangible decisions about what they want because it's going to cost them more.

I can't say that there is an economic informed consent opinion, but that is the type of thing that I think CEJA does look at, and they are looking at issues of stewardship. There's a report that they've written very recently on stewardship; it's in front of the House of Delegates at the AMA.

LUNDBERG: And there's this whole thing about if a doctor makes a mistake, what do you do? You cover it up? Ooh, I don't know. You disclose? Well, yeah. You apologize, but do you have your lawyer sit next to you when you apologize? And the data from Ann Arbor seem to suggest that an apology and an offer to settle, if there are any kind of damages early on, is really good economic policy for an institution. Is there more research going on in that area?

WYNIA: There is a great deal of research on this, and this is a nice intersecting area between the ethical concerns, because the ethical standards on this are actually relatively clear. Patients deserve to have an honest doctor.

LUNDBERG: Right.

WYNIA: And so if you make a mistake, you must disclose that to the patient. That's the ethical standard.

LUNDBERG: And a lawyer in some states will say an apology means there is no defense in a court of law for that error if the patient chooses to sue.

WYNIA: And this is why many states are looking at "I'm sorry" laws, which, in various ways, protect the clinician, whether it's the physician or a nurse or whoever, if they make a mistake and they acknowledge that mistake and apologize for it. That would not be admittable in a court of law under some of these "I'm sorry" laws.

LUNDBERG: Do you have in your head how many states have laws like this now?

WYNIA: I don't actually know the current number. It was 16 or 17 at least, and there may be more.

LUNDBERG: So there's movement more rather than less on that level.

WYNIA: I believe so. That is still a very active area for investigation.

LUNDBERG: Okay, one other thing. You mentioned a very fundamental basis for ethics of a physician in practice? Of course, the AMA was founded in 1846, in large part to create a code of medical ethics, and there are nine principles of ethics. And I've tried for 25 years to get curricula in medical schools to make requiring memorizing the principles of ethics from the AMA originally as part of the curriculum, like a catechism, and I've had no luck whatever. Is there any possible way to get that sort of thing as a fundamental part of a curriculum?

WYNIA: Well, I should admit, first of all, that if you asked me right now to reel off the nine principles, I couldn't do it, so ...

LUNDBERG: But you pulled from one of them about 5 minutes ago.

WYNIA: That's correct, and I mean they're all familiar to me. But I'm just saying, as a catechism, I would not be able to pass that test right now.

LUNDBERG: A boy scout is trustworthy, honest, blah, blah, blah, blah.

WYNIA: That's right.

LUNDBERG: I never forget that.

WYNIA: And I really like the idea, and we have made some headway in this, of bringing the code of ethics and the principles of ethics into the classroom, in part because, even if you as an individual physician or a teacher don't think the AMA's code is right on every instance, there are a number of ways in which the code can affect your life.

There are courts that call upon the code as being the standard of practice with regard to ethical standards. So if you choose to breach a principle of the code, you'd better have a really good argument for that.

LUNDBERG: When you say "court" and you're talking to physicians, they say, "Oh, maybe I better pay attention now."

WYNIA: Right.

LUNDBERG: So I think probably we'll end our discussion on that particular note, Dr. Matt Wynia. Thank you so much for being with us to talk today.

And thank you very much for being with us. I'm Dr. George Lundberg, Editor-at-Large for MedPage Today, signing off.

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.